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Agency Profile
Agency Name
Email Address
Incorporated
Partnership
Individual
Other
Mailing Street Address
City
State
Zip
2nd Street Address (if necessary)
City
State
Zip
Website
Phone
Fax
Date Company was started
Tax ID Number
Agency Contacts
Principal(s)
Key Commercial Producer(s)
Contact CSR/ACSR
Total No of CSRs/ACSRs
Accounting/Bookkeeping
Business Breakdown
Mix of Business
% Commercial
% Personal
Surplus Line vs Standard Lines
% Surplus Lines
Estimated Agency Amount Financed
Average Size Account
Funding Requests:
Fund Agent
Fund MGA/Insurer
ACH (must complete ACH form)
Check/Draft
Who determines placement of financed accounts?
Principal
Producers
CSRs/ACSRs
Others
Miscellaneous Information
Community Interests or Charities
Organizations your company is affilited with
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